This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Sunday, 1 August 2010

Dear Mental Nurses, Doctors...anyone really

What the fuck is going on? I need you to shed some light on something for me.

These people have no medical issues. This is happening a lot lately. I can understand an overdose needing IV parvolex but when they are purely mental health issues we cannot manage them. We don't know what to do with them. Psychiatry is refusing to take them over until we "force feed" these patients. This is something medical doctors and nurses ARE NOT ALLOWED TO DO UNDER ANY CIRCUMSTANCES IN A DISTRICT GENERAL HOSPITAL AND WE DON'T MAKE THE LAWS. We can't section them apparantly as they need to go to their previous psyche facilities for that. News to me. We have resorted to begging these patients to eat, on our hands and knees. This includes the chief exec visiting these patients and doing some begging. The psyches won't take these patients over but will be taking the hospital to court if we don't "make" these people eat, stop threatening suicide etc etc etc.

Why the hell are the medical consultants getting this dumped on them?

The GP's are even sending people to AAU with "anxiety" and no other problems at all. Even if we can get the psyches into see them (mission impossible on a good day), it could take over a week. And medical patients die due to lack of beds, and getting discharged to early to free up more beds.

We have no RMN's on staff so basically we are up shit's creek. The local psychiatric hospitals won't "get involved".

What am I missing here. These patients definitely do NOT have medical issues. No electrolyte imbalances yet.....or confusion related to infection. Nothing like that.

What's going on is 'streamlining' of Mental health service = No beds and no staff. People don't stop becoming unwell, just because there isn't anywhere to put them. You are being used as a dumping overflow, probably for the patients I should be nursing, but have no beds to do this with.

The thing is we have relatives demanding that we essentially tie these people UP and make them eat etc etc, or they demand that we don't discharge them until they stop "wanting to kill themselves".

In a medical setting WE ARE NOT LEGALLY ALLOWED TO FORCE THINGS ON PATIENTS. For any reason. And apparantly sectioning is out of the question.WTF?

So if we force feed we will all lose our jobs, get sued and face criminal charges and if the patient dies of starvation we will lose our jobs, get sued and face criminal charges as some of our medical doctors are finding out.

When the hospital chiefs come to the ward to beg patients to eat to avoid a court case you know the situation is out of control.

I've seen roughly similar situations in CAMHS, involving teenagers with anorexia who are being NG tube-fed. This has occasionally led to arguments between CAMHS and paediatrics as to whether it should be done on the CAMHS inpatient unit or the paeds ward.

CAMHS say it's a physical treatment and should be done on the paeds ward, paeds say it's a psychiatric issue, so it should go to CAMHS. Paeds say that they don't have the skills in managing psychiatric patients, CAMHS say they don't have the skills in NG tube feeding...and so it goes round in a circle.

Personally, I take the view that the most important thing is that it's done rather than who does it. Exactly who should do it ought to depend on a range of issues - whether the person is consenting to treatment and admission, their physical condition, and so on.

In the case you describe, where the patient isn't consenting to treatment, then they should be sectioned (NG tube feeding for anorexia counts as psychiatric treatment, so you can use the Mental Health Act), and then either...

(a) if they're to be kept on the ward, then the trust should be paying for bank/agency RMNs to come onto the ward and deal with the MHA issues and carry out restraint.

or (b) if they're to go onto the psych ward the trust should ensure that the RMNs there are sufficiently skilled at NG tube feeding. If they're not, then the trust should be paying for them to receive training.

In both those cases, note the use of the phrase "the trust should be paying for". I think that might be where the problem lies.

Yep, definitely sounds like a mix of money and politics. Last time we had a dispute like this, it was resolved by escalating the matter to a meeting between the respective clinical directors to come up with an agreement as to how to proceed.

Inmy experience it is because, at the end of the day, the acute medical team will take anyone who is sick that no one else wants.

Other specialties, be they surgeons or psychs, can pick and choose to some extent. That means that GPs know that if they either fail to get the right speciality to take them, don't know which speciality, or just don't try, they can send them off to the medical team to manage. That's how they get into hospital - and once there the same thing applies, other specialties can refuse to take over the care of a patient, particularly if they are based off-site, and/or horrendously underfunded like psych.

Compulsory treatmentOccasionally, someone with anorexia may refuse treatment even though they are severely ill and their life is at risk.In such a situation, doctors may decide to admit the person to hospital for compulsory treatment under the Mental Health Act. This is sometimes called ‘sectioning’ or being ‘sectioned’.

Anonymous: Yes, you can be committed to hospital for compulsory treatment. However, what I believe MMN is saying is that the particular ward that they are working on is not legally allowed to compel patients to accept treatment (vs. some other wards which can).

General Medicine is the long stop for everything. It has always been like that. If somebody has social problems that cannot be managed by social services they are sent to hospital and passed on to general physicians to sort them out. It is the same with psychiatric problems. If the mental health services cannot cope the patients get sent to the general hospital and the general physicians have to do their best. Or the patient is left with the GP.

With the coalition cuts this sort of problem is only going to get worse.

I'm pretty sure you can section a patient with anorexia for force feeding in a general hospital (section would need to be done by a psych though). It is pretty much the only way you can force feed an anorexic patient since they will usually retain capacity.

Medical consultants often have little familiarity with the mental capacity and mental health acts so it is often worth getting an expert opinion. That said there is no way the psychs can threaten the general hospital for not treating the patients - as you say - to force feed without section would be assault - it is up to the psychs to arrange sectioning for the purposes of treatment.

In my part of the uk that would be because mental health staffing and beds are being cut and are the psychiatric ward equivalent of what you so regularly describe happening to your ward, Anne.

I'm a mental health nurse, and of all the blogs I've looked at, yours most accurately reflects what I see going on in mental health.

Despite occupancies of 133%+ over several years now (achieved by juggling beds, sending folk out on leave to use their bed and sleeping new admissions on a sofa, borrowing beds on other wards) there is now talk of cutting more beds.

Community support, rather than being increased to compensate for the lack of inpatient care, is being chipped away at.

They are slashing community beds for elderly as well. We already are overwhelmed with delayed discharges anyway. There is no place for these people to go.

Management has told the RN's that "we had better get off our asses and get these people discharged".

The consultants don't seem to understand the situation. I had one screaming at me the other day. On Friday he had medically discharged a patient to a stepdwon facility. She is 99 and cannot take care of herself. And it will take about 8 weeks to get a NH.

On friday I busted my ass to make 100 phone calls to find a rehab type place to actually accept her. I started on this as soon as the consultant said she was medically stable for discharge from our hospital ward. If you want to know why your nurse is ignoring your call bell it's because we are doing this kind of stuff for 22 patients.

Rehab facility said they will assess her on Tuesday and then it will be a 3 week wait at least because they have no beds. So we won't even know if they will accept her until at least Tuesday. And that was the only place I could get to come and assess her.

Monday morning her consultant was on the ward screaming and cursing at me because "I hadn't bothered to discharge that lady" "Why the fuck is she still here" "these goddamn nurses don't know what they are doing" "How hard is it to handover a patient to the nurses at a rehab facility".

I really wish these consultants would either get to grips with the situation or shut the fuck up.

Oh and then there was all the paperwork I had to complete and send off to get her discharged and under the care of SS.

She is still on the ward today with a lovely hospital acquired chest infection...on IV antibiotics. An hour after we started the IV antibiotics the rehab place rang and said that they will accept her and will have a bed in two days. I told them she was no longer fit for discharge because of her chest infection and IV drugs.

If she is once again declared medically stable we will have to go through the whole process again. Eventually she will die on the ward.

It sucks to be old and frail at the best of times but to be old and frail on an NHS ward....:0(This story is repeated on medical wards across the country and is only going to get worse. Our CCOT nurses are constantly being called to review patients who are on 80% fiO2 and desaturating due to being old, frail and not able to cope with a resp rate of 40 due to a HAI. What can they do? Most often they argue with a doctor over whether a DNAR might be more appropriate as there is no way ICU will take them....most will not tolerate the tight mask needed for NIV and if they get tubed they usually die on the ventilator. Most often the DNAR is not done and low and behold they manage to bypass the review by the medical SpR (a requirement for admission to the HDU for NIV) and a snotty consultant will browbeat an anaesthetic SpR to admit to the ICU (time and time again this happens as they know damn well that getting hold of the ICU consultant will=no admission). The medical SpRs manage to hold their ground because (a)they can get hold of the consultant easily and (b) she is well known for eating other consultants for breakfast. Most of the time our SpRs are on their own as getting hold of the ICU consultant is alot harder as they have a bigger patch to cover ( theatres, ED plus the rest of the hospital). This is why they are pushing for CPAP and NIV to be available on general medical wards. Can you imagine it? Who will do the ABGs? Who will make sure that all NIV patients keep their masks on, are not accidentally being fully ventilated ( it happens alot on HDU due to the safety settings on some of the NIPPY machines)and have NG tubes so that they can be fed? We can use mittens as a firstline and sedation as aback-up but this is because we have one or two patients to look after. It beggers belief how anyone thinks that this is a good idea. I have contacted the RCN and the NMC with no luck or back-up. Big fat suprise.

You know dino every time I try to tell people about what is going on they say the same thing

"Well dear have you bothered to call the union"

"Have you bothered to put in incident forms"

"Have you bothered to contact the NMC/RCN"

"Have you bothered to contact the newspapers"

"Have you bothered to whistleblow, it is the nurse's responsibility you know"

Um. OF COURSE WE FUCKING HAVE DONE ALL OF THE ABOVE AND MORE. And everything that Joe Public can think of we have already thought of, everything he can suggest we have DONE. And we have done all the things that Joe Public is to fucking ignorant to think of on his own.

"What am I missing here"- well the first bit is easy. It sounds like your ward needs to establish a more effective referral mechanism?

Most hospital based services usually require a medic (or nurse) to ACCEPT a GP referral first before deciding if a ward area (rather than A&E) is the most appropriate setting to begin investigating a new patient.

It simply beggars belief that a cohort of patients are being sent to an acute medical setting even though none of them have an actual physical problem.What next - sending patients with unstable angina to a forensic psychiatric setting?

The decision to impose treatment on any patient refusing intervention MUST be judged on the individual set of circumstances in each case.At least two factors must be ALWAYS be kept in mind;[1] does the patient have capacity?[2] the likely consequences of NOT treating a particular problem - for example, a young person who has starved themselves and now has a potassium of 8.3, say.

In other words, once a life threatening problem has been identified staff would be entitled, and in fact required, to act in the patient's 'best interest' in order to save their life (assuming they were lacking in capacity).

The MHA can be used on a medical ward (or other in-patient areas) to detain somebody - by applying either the nurses holding power, Section 5(4) or a medics holding power Section 5(2) - although these sections DO NOT permit enforced treatment (rather their function is to enable more detailed psychiatric assessment).

As mentioned above 'common law' must be used to treat a physical emergency, providing there is evidence that a patient lacks capacity, and the consequences of not treating the problem are likely to be significant.

Incidentally, for those interested in the legality of imposed feeding (for patients suffering with anorexia) this landmark case makes for very interesting readinghttp://webjcli.ncl.ac.uk/articles3/keywood3.html

Despite rulings made following B v Croydon Health Authority, the issues surrounding feeding without consent remain about as clear as mud?

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.